2001
Public Health Service
Primary Care Policy Fellowship

Mainstreaming Care Coordination for People with Complex Health Care Needs

Caroline Blaum, M.D., M.S.
American Geriatric Society
Visiting Assistant Professor, Department of Internal Medicine, Johns Hopkins University

Barbara A. Douglass, C.N.M, M.S.N., M.B.A.
American College of Nurse- Midwives
President/Chief Executive Officer, Nurse Midwifery Associates of the Bay Area

Lucy N.Marion, Ph.D., R.N., F.A.A.N.
National Organization of Nurse Practitioner Faculties
Associate Dean, University of Illinois at Chicago College of Nursing

Eduardo Olivarez
Substance Abuse Mental Health Services Administration
Chief Executive Officer, Rio Grande Valley Council on Alcohol and Drug Abuse

Cecilia M. Prela, Pharm D.
Health Care Financing Administration
Pharmacist/Statistician, Division of Clinical Standards and Quality, Region 10

 Robert E. Scalettar, M.D., M.P.H.
American Association of Health Plans
Vice President of Medical Policy and Chief Medical Officer, Anthem Blue Cross and Blue Shield

Dean Schillinger, M.D.
Society of General Internal Medicine
Assistant Professor of Medicine, Director of Clinical Operations, San Francisco General Hospital, University of California San Francisco

Purpose

To improve the quality and cost-effectiveness of care by mainstreaming coordination of care for Medicare and Medicaid beneficiaries.

Scope and Significance of the Problem

The demand for complex health care in the US is staggering and growing exponentially. Longer lives and modern health care result in people with more chronic and comorbid conditions. This increasing complexity is common not only among seniors and other populations with chronic disease and disability, and also among other high-risk populations. These risks include alcohol and substance abuse, mental health problems, immigrant and minority status, residence in inner cities and rural areas, technology-intensive conditions, and low socioeconomic status with insurance deficits. Management of such complex health needs requires sophisticated coordination of health care, including coordination of social services.

Lack of care coordination can have dire long-range consequences on cost and quality. Two thirds of Medicare beneficiaries have 2 or more chronic conditions which accounts for 95% of all Medicare spending. Those with 2 chronic conditions see on average 7 physicians per year; for that .1 percent with 10 chronic conditions, the number escalates to an average of 42 physicians per year. Utilization of multiple providers and sites often leads to fragmented health care and over-utilization of pharmaceuticals, medical errors, and repeated costly hospitalizations. Improving health care coordination provides an opportunity to reverse these costly and adverse outcomes.

Because of the lack of interdisciplinary professional care coordination, family members must provide these services with a concomitant loss of work and income with associated losses to the workforce. The cost of care coordination by family members has a conservative estimate of $115 billion for 1997. Family members are not trained in care coordination and cannot be expected to be efficient or effective. Furthermore, the US is experiencing an increase in the number of elders in relation to younger members of society, a change that will result in fewer family members to care for the aging population. Access to high-quality and cost-effective care coordination is essential to decrease the burden to family members and to decrease the impact on the US economy.

Current Strategies for Care Coordination in US Health Care

Primary care providers coordinate care during scheduled office visits, usually in the context of multiple competing diagnostic and treatment demands. A number of individual programs and projects include high quality care management. Examples include perinatal care coordination in California, chronic disease management programs pioneered by managed care organizations, evidence-based HIV prevention programs, and case management programs for high-risk individuals, such as the frail elderly and rural populations. Care coordination has led to improved quality of care, fewer hospitalizations, reduced costs, and improved quality of life for vulnerable persons and their families.

There are a number of limitations in the current system for coordination of care. Reliance on health care providers to coordinate care during brief visits, without incentives to do so, leads to inadequate care coordination. Not surprisingly, there is tremendous variation in the extent to which people have access to care coordination services, and, when accessed, there is variation in the extent to which these services match the needs of patients. Care coordination is by and large limited to managed care settings and federal or state demonstration projects. Care coordination in the managed care setting, while pioneering and successful, is at times confounded by conflicts of interests. Furthermore, few settings actually integrate social services with medical services. The greatest limitation is that a small proportion of those in need receive services and the actual coordination is hit or miss throughout the system.

Recommendations

Therefore, to mainstream high quality, cost-effective coordination of care services for Medicare and Medicaid beneficiaries, we recommend the following requisite activities:

• Expand the billable activities for coordination of care to go beyond the office walls, e.g. telephone contacts with patient, family, and other medical and social service providers; technology-based home monitoring and treatment;
• Define the types of providers who can provide and bill for care coordination services, including physicians, nurse practitioners, physician assistants, certified nurse midwives, and other professionals, such as social workers, as the Secretary deems appropriate;
• Define eligibility requirements for people to receive care coordination;
• Set efficient and effective methods to assure quality of care coordination, continuously evaluating the impact on health outcomes, and preventing fraud and abuse; and
• Fund research and development for care coordination systems, including use of information technology and tele-health.

To achieve these recommendations, the Primary Care Policy Fellows of the Class of 2001 respectfully request that the Secretary:

• Support Senate Bill 775, The Geriatric Act of 2001, and also promote expansion of the S775 care coordination principles and actions to include other vulnerable populations; and
• Convene a multidisciplinary Care Coordination Task Force, including beneficiaries, family care-givers, primary care providers, HCFA and HRSA officials, and disease management and evidence-based prevention experts. The purpose of the Task Force will be to identify and overcome barriers, plan for necessary research and development, and to develop and implement a plan for mainstreaming care coordination throughout the Medicare and Medicaid health care delivery systems.

References

Arno, P., Levine, C., & Memmott, M. (1999). The economic value of informal caregiving. Health Affairs, 18(2), 182-188.

Chen, A., Brown, R., Archibald, N., Aliotta, S., & Fox, P. (2000). Best practices in coordinated care. Contract HCFA 500-95-0048 (04) Mathmatica Policy Research, Inc.

HCFA Program Memorandum Intermediaries/Carriers, August 7, 2000 (Change Request 1116). Claims processing instructions for Medicare coordinated care demonstration, HCFA, Washington DC.

Leveille, S., Wagner, E., Davis, C., Wallace, J., LoGerfo, M., & Kent, D. (1998). Preventing disability and managing chronic illness in frail elderly adults: a randomized trial of a community-based partnership with primary care. Journal of American Geriatric Society, 46(10), 1314-6.

Quinn, J. & Prybylo, M., Pannone, P. (1999). Community care management across the continuum. Journal of Case Management, 1(4), 223-229.

Wagner, E., Austin, B., & Von Korff, M. (1996). Improving outcomes in chronic illness. Managed Care Quarterly, 4(2), 12-25.

Robert Wood Johnson Foundation

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